In line with its global strategy for health, nutrition, and population, the World Bank Group provides financing, state-of-the-art analysis, and policy advice to help countries expand access to quality, affordable health care; protects people from falling into poverty or worsening poverty due to illness; and promotes investments in all sectors that form the foundation of healthy societies.
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This review represents an attempt to
bridge the significant knowledge gaps on the private health
sector in Sri Lanka, and foster a dialogue on opportunities
for collaboration... Show More + between the government and the private
sector. It accomplishes this through a systematic collection
and analysis of primary and secondary data on the provision,
financing, and regulation of health care services. On health
service delivery, the review finds that the private sector:
includes a range of providers; focuses primarily on curative
and outpatient services rather than preventive services; is
heavily dependent on the public sector for its supply of
human resources; and is concentrated in urban areas. The
quality of health care services in Sri Lanka in both the
private and public sectors, while better than in most
developing countries, still lags behind those in more
advanced countries. There is also little systematic dialogue
and collaboration between the public and private sectors. On
financing, the review finds that private health expenditure
is more than half of total health expenditure, mostly in the
form of out-of-pocket payments by households, with clear
implications for Sri Lanka's progression toward
universal health coverage. On stewardship and regulation,
there is a clear and urgent need to bridge the existing gaps
in the legal and regulatory framework, and in the
enforcement of health regulations applicable to the private
sector, as well as to create an enabling environment for
more effective private sector participation in the health
sector. The review demonstrates that the private health
sector in Sri Lanka is a growing force, due both to greater
investment from private players as well as greater demand
from the population. The review highlights areas where a
more effective engagement with the private sector could
ensure that Sri Lanka is able to offer its citizens
universal access to good quality health service while also
stimulating economic growth. Show Less -

Drawing on three sources, a 2013
qualitative study in four districts of Punjab province; a
targeted analysis of the baseline and end line surveys of
the Family Advancement... Show More + for Life and Health (FALAH 2007-2012)
project; and the Pakistan Demographic Health Survey (PDHS)
of 1990-1991 and of 2006-2007, this study explores Pakistani
(especially Punjabi) couples' dynamics during their
decision processes on fertility intentions and practices,
along with community perceptions of male-focused
interventions as well as men's suggestions for future
intervention strategies. It finds that men in Punjab seem
now more concerned about their fertility intentions and
practices due to the financial challenges of raising large
families. This concern has not only increased spousal
communication about family size and contraceptive use but
has also encouraged Punjabi men to practice family planning.
Most men now realize that either they or their wives should
use family planning. It is the next step, however, of
translating intention into practice, which is a challenge.
Supply-side issues, including absence or paucity of family
planning services as well as poor quality of services
(including service providers' lack of capability to
manage side effects) are the main factors hindering
couples' adoption of family planning. Perceived or
experienced side effects of contraceptive methods are other
factors. Men's positive attitudes and their readiness
to be involved in family planning programs suggest that the
efforts of convincing men to use contraceptives have been
effective and this it is now time for direct reproductive
health interventions for men in Punjab. Yet heavy spending
on media campaigns may not be as effective as interpersonal
interventions. A focused effort to mobilize men through
male-specific interventions is likely to increase the demand
for contraceptives. These interventions have to be backed up
by improved supply of contraceptives and availability of
family planning services in accessible facilities. Show Less -

The South Asia Food and Nutrition
Security Initiative (SAFANSI), established in 2008, sets out
to promote innovation and reform of food and
nutrition-related policies,... Show More + with the goal of improving Food
and Nutrition Security (FNS) in the region. SAFANSI places
particular attention on the political economy of FNS in
South Asia, with an objective of increasing the commitment
of government and development partners to more effective and
integrated food and nutrition-related policies and
investments (SAFANSI 2010). This paper has three main
objectives: (1) to review the literature on applied
Political Economy (PE), particularly as it relates to food
and nutrition security; (2) to define different types of
Political Economy Analysis (PEA), present a method for
conducting an in-depth PEA for food and nutrition-related
policies, and provide an example of an in-depth PEA; and (3)
to present a tool for conducting a rapid assessment PEA of
political commitment for food and nutrition security. The
paper confronts two major challenges. First is the lack of
clarity about what constitutes political economy analysis,
including what its main objectives are, how it is conducted
and used in practice, and who should be using it. It covers
both economic and political forms of analysis, includes both
quantitative and qualitative approaches, and does not have a
single consensus definition in theory or practice. The paper
is aimed primarily at policy analysts working in the area of
food and nutrition policy, especially those who seek to give
guidance to policymakers and development partners. The paper
discusses three different types of applied political economy
analysis, based on different needs, purposes, and resources
(especially time, money, and expertise). Show Less -

India faces significant challenges in
attracting qualified health workers to rural areas. In 2010
the authors conducted a Discrete Choice Experiment (DCE) in
the Indian... Show More + states of Uttarakhand and Andhra Pradesh to
understand what health departments in India could do to make
rural service more attractive for doctors and nurses.
Specifically, we wanted to do the following: (a) examine the
effect of monetary and nonmonetary job attributes on health
worker job choices; and (b) develop incentive
'packages' with a focus on jobs in rural areas.
The study sample included medical students, nursing
students, in-service doctors and nurses at primary health
centers. An initial qualitative study identified eight job
attributes health center type, area, health facility
infrastructure, staff and workload, salary, guaranteed
transfer to city or town after some years of service,
professional development, and job in native area.
Respondents were required to choose between a series of
hypothetical job pairs that were characterized by different
attribute-level combinations. Bivariate probit and mixed
logit regression was used for the statistical analysis of
the choice responses. The findings suggest that the supply
of medical graduates for rural jobs remained inelastic in
the presence of individual monetary and nonmonetary
incentives. In contrast, the supply of nursing students for
rural jobs was elastic. Further, medical and nursing
students from rural areas had a greater inclination to take
up rural jobs. The supply of in-service doctors and nurses
for rural posts was elastic. Higher salary and easier
enrolment in higher education programs in lieu of some years
of rural service emerged as the most powerful driver of job
choice. Overall, better salary, good facility
infrastructure, and easier enrolment in higher education
programs appear to be the most effective drivers of uptake
of rural posts for students and in-service workers.
Combining these incentives can substantially increase rural
recruitment. Incentivizing medical graduates to take up
rural service appears to be challenging in India's
context. This can be improved to some extent by offering
easier admission to specialist training and recruiting
students from rural backgrounds. In contrast, nursing
students and in-services nurses are much more receptive to
incentives for uptake of rural service. This suggests that
cadres such as nurse practitioners can play an important
role in delivering primary care services in rural India. Show Less -

This series is produced by the Health,
Nutrition, and Population (HNP) Family of the World
Bank's Human Development Network. The papers in this
series aim to provide... Show More + a vehicle for publishing preliminary
and unpolished results on HNP topics to encourage discussion
and debate. Pakistan has one of the highest infant mortality
rates in the world, and over 50 percent of deaths in
post-neonatal children are attributable to pneumonia,
diarrhea, or meningitis diseases that can be prevented
through vaccination. The purpose of the study is to compare
the cost-effectiveness and financial implications of
introducing pneumococcal (PCV-10), rotavirus (Rota-Teq), and
Homophiles influenza type B (Hib) vaccines in Pakistan. The
cost-effectiveness analysis was conducted using the Tri-Vac
model, which is a static model that estimates the burden of
disease and the costs of treatment and for the immunization
program of children up to five years old in ten annual birth
cohorts (2010 to 2019). Sensitivity analyses were conducted
testing key assumptions related to disease burden, vaccine
efficacy, and vaccine cost. The analysis of financial
implications included a projection of cold chain needs and
costs associated with the introduction of each new vaccine,
as well as the financial outlays required by the government.
Sensitivity testing was also conducted on major assumptions.
All three vaccines were found to be cost-effective, with Hib
vaccine the most cost-effective option at $22 per
disability-adjusted-life-year (DALY). The cost-effectiveness
figures for PCV and rotavirus vaccines were $225/DALY and
$201/DALY, respectively. Sensitivity testing did not
significantly alter the results. The combined financial
requirement for the three new vaccines would peak in 2017 if
GAVI assistance reduced to five rather than eight years
($213m). This cost would account for 40 percent of national
immunization expenditures, and 15 percent of government
health expenditures. Required cold chain investments would
be small relative to the expenditure on vaccines, and
represents a good return on investment. While the investment
would be worthwhile from an economic perspective,
introducing all three vaccines in Pakistan will present
financial challenges unless overall health spending
increases. Careful consideration needs to be given to
long-term financing after GAVI support ends. Show Less -

When the author thinks about the damages
caused by conflict, a lot of images come immediately to our
minds: destruction, casualties, collapsed infrastructure,
devastated... Show More + cities and communities, broken families and pain.
But they tend to pay less attention to other invisible
wounds that last for years and cause deep scars on people
and on development: those caused by conflict on mental
health. During the last 30 years, Afghanistan has been
impacted in many ways by conflict. One can hardly find an
Afghan family which has not lost one or more members in this
period due to conflict. Over one million people have been
killed, one million are disabled and millions either
migrated abroad or are internally displaced. Conflict and
other factors such as unemployment, general poverty,
breakdown of community support services, and inadequate
access to health services have not only damaged the social
infrastructure of the nation, but also caused mental health
disorders mostly in vulnerable groups like women and
disabled people. Half of the Afghan population aged 15 years
or older is affected by at least one of these mental
disorders: depression, anxiety and post traumatic stress
disorder. These disorders contribute to community and
domestic violence and to the high levels of malnutrition in
the country as they adversely affect maternal care giving in
diverse ways. In addition, social restrictions and taboos
are big challenges for women's access to mental health
services in Afghanistan. Mental health in the country is a
topic that needs to be better understood. This policy note
'Mental Health in Afghanistan, Burden, Challenges, and
the Way Forward' aims to contribute to the debate on
this development priority and explores some options on how
mental health challenges could be addressed. The Government
of Afghanistan and the Ministry of Public health are
committed to address the major public health challenges that
the country faces. The country has made significant progress
in order to provide a quality package of basic health
services to Afghans. This note is a contribution to those
ongoing efforts. Show Less -

The Government of India has publicly
committed to a doubling or trebling of government health
spending by 2012 and launched a major program, the National
Rural Health... Show More + Mission (NRHM), to help spend the additional
funds and achieve better health outcomes. This paper reviews
recent data on trends in government spending and various
scenarios of central and state funding to assess the
feasibility of achieving these financing goals. The goal of
2 percent of Gross Domestic Product (GDP) for government
health spending is unlikely to be achieved, although there
is clear evidence of program growth. Much larger state-level
spending is needed to accelerate overall government spending
in India's federal system. In addition, there is
evidence of constraints in the ability to spend
significantly increased budgets in a timely way and possible
state substitution of increased central funding for existing
state budgets. Significantly increasing government health
spending in India requires more than simply raising budgets
at the central level. NRHM does show some positive effects,
but the rapid gains envisaged will require greater efforts
to address the shortcomings of government systems and
creative approaches to India complex federal financing system. Show Less -

The paucity of qualified health workers
in rural areas is a critical challenge for India's
health sector. Although state governments have instituted
several mechanisms,... Show More + salary and non-salary, to attract health
workers to rural areas, individually these mechanisms
typically focus on single issues (e.g. salary). This
qualitative study explores the career preferences of
under-training and in-service doctors and nurses and
identifies factors important to them to take up rural
service. It then develops a framework for clustering these
complex attributes into potential ?incentive packages for
better rural recruitment and retention. The study was
carried out in two geographically diverse Indian states,
Uttarakhand and Andhra Pradesh. A total of 80 in-depth
interviews were conducted with a variety of participants:
medical students (undergraduate, postgraduate, and Indian
system of medicine), nursing students, and doctors and
nurses in primary health centers. The information collected
was clustered by constructing several hierarchical displays,
and collated into job-attribute matrixes. The findings
indicate that, while financial and educational incentives
attract doctors and nurses to rural postings, they do not
make effective retention strategies. Frustration among rural
health workers often stems from the lack of infrastructure,
support staff, and drugs, a feeling exasperated by local
political interference and lack of security. Show Less -

This case study analyzes the reasons for
adoption and the implementation process of a key policy in
Chhattisgarh state, India, to create a rural cadre of
trained physicians... Show More + in order to address the acute shortage of
doctors in the state's primary health facilities. It
documents the experience specific to Chhattisgarh state, but
with its attention to the policy processes and
implementation challenges associated, it also highlights the
necessity of a political economy perspective currently
missing in much of the published literature on human
resources for health. A principal lesson of this case
concerns why it matters how interests of various
stakeholders who had interests in the three-year course are
included early in the policy process, namely the anticipated
opposition of the medical doctor community represented by
the Indian Medical Association (IMA) and the interests of
the students themselves and their desire to be given
appropriate status as medical doctors. This case study
addresses the legal hurdles faced and the importance of
institutional support structures to maintain quality
standards and provide for grievance procedures. Through this
case study, it also becomes apparent why the role of
institutional ownership of policy matters rather than
success or failure of policy that is linked entirely to the
authority of a few key appointed officials. Show Less -

Focusing on the Integrated Child
Development Services (ICDS), Indias largest nutrition and
early child development program, this paper describes the
political, organizational,... Show More + and technical challenges in
building and sustaining an outcomes-oriented approach to
nutrition program monitoring. The author show that the
current policy environment appears to be conducive to
strengthening nutrition program monitoring: political
commitment is growing, financial allocations to ICDS have
increased and, recently, a number of reforms to strengthen
the ICDS monitoring and evaluation system have been
undertaken. Yet, substantial weaknesses remain. This paper
discusses some of the challenges in converting this vision
into action and suggests some immediate steps that could be
considered both at the central and state levels. Show Less -

Despite India's great strides since
independence, fertility, mortality, and morbidity remain
unacceptably high. Although poverty and low levels of
education are the... Show More + root causes of poor health outcomes, poor
stewardship over the health system bears some
responsibility. Although India's states exhibit a wide
variation in health outcomes, all but the best-performing
states need to focus on improving both sexual and
reproductive health care and child health care, and on
reducing communicable diseases for the poor. This paper
examines the public and private responses to this situation
detailing the reasons behind the failure of the public
sector and ways in which the private sector can be
encouraged to play a role in providing health care for the
poor in India. The paper concludes that there are three
promising areas for the private sector including; (i)
contracting out the primary health centers, (ii) social
franchising and (iii) demand-led financing. The study is
focused on what to do to improve health care for the poor,
while a series of separate background papers focus on how to
do it, and state specific issues in Andhra Pradesh, Bihar,
Karnataka, and Punjab. Show Less -

This paper presents 'a rapid
private health sector assessment' for Karnataka.
Karnataka is a middle-tier Indian state with most state-wide
health indicators mirroring... Show More + those for the nation as a whole.
In addition to these health statistics, more than half of
Karnataka's children suffer from malnutrition.
Improving primary health care services is a key to improving
these health indicators. Improving health outcomes will
depend on improving the quality, outreach and responsiveness
of primary health care providers. Government can consider
scaling up the successful experiences of community health
care financing. More specifically the findings of this study
and the discussion that it engenders will be used to inform
the design of the proposed Karnataka Health Nutrition and
Population (HNP) project. Karnataka currently has 1,685
Primary Health Center's (PHCs) and 583 Primary Health
Units (PHUs). The PHC is intended to serve a population of
30,000 with smaller populations in the more remote rural or
hilly areas and larger populations covered in urban areas.
It is reported that the PHCs are not currently able to
fulfill all these functions, many of which have a strong
public good component. As such, the private sector can still
play a role in delivering these services, although they will
have to be funded by the public sector. Some services will
have a mixture of public and private good characteristics,
while others will be purely private goods. It is the latter
group of services that are most amenable to
privately-funded, privately provided health care. In
general, the public health care system is managed and
overseen by the district health officers. Although they are
qualified doctors, they have little or no training in public
health management and are transferred frequently. Moreover,
even if they had the training they do not have the
flexibility to reallocate financial, capital and human
resources to achieve better outcomes. Show Less -

The use of communication by the leprosy
program in India offers valuable lessons for other programs,
both in terms of its successes as well as the challenges
ahead.... Show More + The information, education and communication
component has made a significant contribution in reducing
the prevalence rate of leprosy cases. It has raised
awareness about the signs and symptoms of leprosy and the
importance of seeking early treatment, and reduced the
social stigma associated with the disease. In recent years,
the program emphasis has shifted to early voluntary
self-reporting. The Government of India has set itself the
goal of eliminating leprosy at the national level by
December 2005. In the last vital year, cost-effective
communication efforts have to be planned and sustained in
collaboration with key partners to improve service delivery
to hard-to-reach groups, motivate general health system
staff, and ensure district-level political support. Show Less -

The Tamil Nadu Nutrition Program (TINP)
is one of very few around the world that has reduced
malnutrition on a large scale, and over a long period. It
did well because... Show More + it coupled good strategies and strong
commitment at the sectoral level with good micro-design at
the field level. Success factors included intensive sector
analysis prior to the program's design, which helped
build political and financial commitment to nutrition, as
well as a sound technical basis for the program ; careful
choice of committed managers, at least during the first ten
years ; using paid village level workers, resulting in low
drop-outs and high motivation ; well designed recruitment
criteria, ensuring that field workers were competent and
acceptable to clients ; a carefully planned training and
supervision system, which was entirely field rather
institution based-a model worth testing in other countries ;
a focus on a small number of interventions, tightly targeted
on high risk clients, which made field workers' jobs
feasible ; an efficient management information system,
which provided rapid feedback to clients at the local level,
as well as program managers ; involving local communities
through information campaigns before the program began, and
using women's and children's groups to help with
implementation. But TINP was not an unqualified success, and
much can be learned from its weaknesses: the commitment and
integrity of program management declined substantially after
the first ten years, program performance might have suffered
less if local communities had been empowered to play a
greater role in worker supervision and quality control; the
health referral system never worked well, and more could
have been done to identify food insecure families, and
enroll them in existing food security programs; TINP's
support systems in nutrition communications, operational
research and program evaluation remained weak, because
capacity strengthening plans were not developed for them the
Bank failed to carry out analytical work on management and
capacity development issues, despite continuing capacity
constraints in the nutrition program. Show Less -

Every year, Ministries of Health the
world over develop annual budgets for the health sector.
Every year, donors, academicians, advocacy groups, medical
trade unions... Show More + and professional organizations, and health
service managers and providers complain that the budgets
have the wrong priorities. While all these groups are united
in their unhappiness with the priorities reflected in these
budgets, they disagree on what the priorities should be and
on how the prioritization process should be conducted. A
review of the published literature reveals a lack of
consensus in the policy and academic communities on how best
to prioritize health sector budgets. What is more surprising
is that the literature review reveals little documentation
on how countries actually do prioritize health expenditures.
This paper attempts to address both gaps in information
about prioritization. The first part of the paper describes
hat goes into a prioritization exercise. This typically
includes advocates, prioritization criteria, and
methodologies for making choices. The first part also
describes the analytical tools available to understand who
gains and who loses from decisions taken in developing a
budget for the health sector. The second part of the paper
documents and actual prioritization exercise undertaken in
Bangladesh between the years 1996 and 1999. As the title of
this paper indicates, this is not a theoretical or academic
paper. It is simply meant to empower potential practitioners
by introducing them to the players involved in the process,
the techniques utilized by these players, the political
realities that drive the process, and some evaluation techniques. Show Less -

This paper reviews the existing
community-based and self-financing health insurance schemes
in India catering to the general population as well as
addressing the needs... Show More + of the poor and vulnerable section of
the society. Also discussed are some critical issues of
accessibility and use of health care services, out-of-pocket
expenditure on treatment and the need for health insurance
for poor households pursuing varied occupations in both
rural and urban areas. The paper examines in detail the
determinants of enrollment in the community-based financing
scheme, using the household-level data from the pilot study
undertaken in Gujarat (India). It also investigates the
issue of how much health insurance mitigates the
households' burden of health care expenditure. The
findings suggest that the community plan fairly addresses
equity in enrollment but that, in terms of providing financial Show Less -

This paper assesses the impact of the
Self-Employed Women's Association's (SEWA's)
Medical Insurance Fund, Gujarat, in terms of inclusion of
the poor, hospital utilization,... Show More + and expenditure. Age-matched
insured and uninsured women were compared using survey data
(2000). The authors found that wealth was not a determinant
of membership in the Fund; i.e., the poor were not excluded.
Of 28 hospitalizations among Fund members over one year,
only five were reimbursed. Membership in SEWA was not
significantly associated with increased frequency of
hospitalization, but there was a significant association
with lower costs of hospitalization, net of reimbursement.
Unlike many other CBHI schemes, the Fund has overcome
barriers that exclude the poorest. This is due in part to
nesting of the Fund within a larger development
organization. Utilization of the Fund, and thus impact on
hospital utilization and expenditure, was minimal. This may
relate to a lack of awareness of benefits among Fund
members, or costs and difficulties associated with
submitting an insurance claim. Show Less -

This paper summarizes empirical findings
from recent World Bank financed analysis on the use of
health services by the poor in India (Mahal et al 2000) and
some additional... Show More + analysis conducted with the same data. Three
factors motivate the choice of approach taken here and in
the background paper. First, the size of the population, the
diversity within India, and the unique governance structure
provide an opportunity for comparative analysis to support
learning about equity in health service use. This led to
analysis below the national level where state-level
comparisons are used. This paper and the analytical work
supporting the findings summarized in it are part of a set
of studies intended to provide information for public and
professional discussion around the shape of India's
future health system. Other studies included private health
sector analysis, consumer protection in the health sector,
health insurance, pharmaceutical sector analysis, and
analysis of the quality of health services. The underlying
purpose is to find ways to improve health outcomes in India,
particularly for the poor, and to develop sustainable health
systems and financing to achieve better health outcomes. The
whole effort originated out of a longstanding dialogue
between the Government of India and the World Bank. A brief
description of the data and methodology is presented in the
next section. A summary of national- level findings is
provided and state-level findings are also discussed. A
discussion of the relevance of the findings, including study
limitations, is presented in the final section. Show Less -

The figures presented in this
publication describe the health, nutrition, and population
(HNP) status, and service use among individuals belonging to
different socio-economic... Show More + classes. The figures are intended
to provide the Bank operational staff, and government
officials with whom they work, basic information for their
use in preparing country analyses, and in developing HNP
activities for the disadvantaged. The document represents an
initial effort to provide basic information about health,
nutrition, and population conditions and service use by
socioeconomic class within countries. It discusses the most
significant technical issues encountered in preparing the
information, such as the descriptive nature of
relationships, and expands on the implications of an asset
approach, as measures of socioeconomic status. Accompanying
each of the rates presented in the total population table
are the values for two statistical indictors of inequality:
poor/rich ratio, and concentration index. While most
findings reported herewith, are in line with expectation,
there are exceptions, and anomalies that require further investigation. Show Less -